Form 8853
Department of the Treasury
Internal Revenue Service (99)
Archer MSAs and
Long-Term Care Insurance Contracts
Go to www.irs.gov/Form8853 for instructions and the latest information.
Attach to Form 1040 or Form 1040NR.
OMB No. 1545-0074
2018
Attachment
Sequence No.
39
Name(s) shown on return
Social security number of MSA
account holder. If both spouses
have MSAs, see instructions
Section A. Archer MSAs. If you have only a Medicare Advantage MSA, skip Section A and complete Section B.
Part I
Archer MSA Contributions and Deductions. See instructions before completing this part. If you are filing
jointly and both you and your spouse have high deductible health plans with self-only coverage, complete a
separate Part I for each spouse.
1 Total employer contributions to your Archer MSA(s) for 2018 . . . . 1
2
Archer MSA contributions you made for 2018, including those made from January 1, 2019,
through April 15, 2019, that were for 2018. Don't include rollovers. See instructions . . . . .
2
3 Limitation from the Line 3 Limitation Chart and Worksheet in the instructions . . . . . . . 3
4
Compensation (see instructions) from the employer maintaining the high deductible health plan. (If
self-employed, enter your earned income from the trade or business under which the high
deductible health plan was established.) . . . . . . . . . . . . . . . . . . .
4
5
Archer MSA deduction. Enter the smallest of line 2, 3, or 4 here. Also include this amount on
Schedule 1 (Form 1040), line 36, or Form 1040NR, line 34. On the dotted line next to Schedule 1
(Form 1040), line 36, or Form 1040NR, line 34, enter “MSA” and the amount . . . . . . . .
5
Caution: If line 2 is more than line 5, you may have to pay an additional tax. See instructions.
Part II
Archer MSA Distributions
6a Total distributions you and your spouse received in 2018 from all Archer MSAs (see instructions) . 6a
b
Distributions included on line 6a that you rolled over to another Archer MSA or a health savings
account. Also include any excess contributions (and the earnings on those excess contributions)
included on line 6a that were withdrawn by the due date of your return. See instructions . . . .
6b
c Subtract line 6b from line 6a . . . . . . . . . . . . . . . . . . . . . . . 6c
7 Unreimbursed qualified medical expenses (see instructions) . . . . . . . . . . . . . 7
8
Taxable Archer MSA distributions. Subtract line 7 from line 6c. If zero or less, enter -0-. Also
include this amount in the total on Schedule 1 (Form 1040), line 21, or Form 1040NR, line 21. On
the dotted line next to Schedule 1 (Form 1040), line 21, enter “MSA” and the amount . . . . .
8
9a
If any of the distributions included on line 8 meet any of the Exceptions to the Additional
20% Tax (see instructions), check here . . . . . . . . . . . . . . . . . .
b
Additional 20% tax (see instructions). Enter 20% (0.20) of the distributions included on line 8 that
are subject to the additional 20% tax. Also include this amount in the total on Schedule 4 (Form
1040), line 62, or Form 1040NR, line 60. Check box c on Schedule 4 (Form 1040), line 62, or box b
on Form 1040NR, line 60. Enter “MSA” and the amount on the line next to the box . . . . . .
9b
Section B. Medicare Advantage MSA Distributions. If you are filing jointly and both you and your spouse received
distributions in 2018 from a Medicare Advantage MSA, complete a separate Section B for each spouse.
See instructions.
10 Total distributions you received in 2018 from all Medicare Advantage MSAs (see instructions) . . 10
11 Unreimbursed qualified medical expenses. See instructions . . . . . . . . . . . . . 11
12
Taxable Medicare Advantage MSA distributions. Subtract line 11 from line 10. If zero or less,
enter -0-. Also include this amount in the total on Schedule 1 (Form 1040), line 21, or Form
1040NR, line 21. On the dotted line next to Schedule 1 (Form 1040), line 21, enter “Med MSA” and
the amount . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12
13a
If any of the distributions included on line 12 meet any of the Exceptions to the Additional
50% Tax (see instructions), check here . . . . . . . . . . . . . . . . . .
b
Additional 50% tax. Enter 50% (0.50) of the distributions included on line 12 that are subject to
the additional 50% tax. See instructions for the amount to enter if you had a Medicare Advantage
MSA at the end of 2017. Also include this amount in the total on Schedule 4 (Form 1040), line 62,
or Form 1040NR, line 60. Check box c on Schedule 4 (Form 1040), line 62, or box b on Form
1040NR, line 60. Enter “Med MSA” and the amount on the line next to the box . . . . . . .
13b
For Paperwork Reduction Act Notice, see your tax return instructions.
Cat. No. 24091H
Form 8853 (2018)
Form 8853 (2018)
Attachment Sequence No. 39 Page 2
Name of policyholder (as shown on Form 1040)
Social security number of
policyholder
Section C. Long-Term Care (LTC) Insurance Contracts. See Filing Requirements for Section C in the instructions
before completing this section.
If more than one Section C is attached, check here . . . . . . . . . . . . . . . . . . . . . .
14a Name of insured
b Social security number of insured
15
In 2018, did anyone other than you receive payments on a per diem or other periodic basis under a
qualified LTC insurance contract covering the insured or receive accelerated death benefits under a life
insurance policy covering the insured? . . . . . . . . . . . . . . . . . . . . . . .
Yes No
16 Was the insured a terminally ill individual? . . . . . . . . . . . . . . . . . . . . . .
Yes No
Note: If “Yes” and the only payments you received in 2018 were accelerated death benefits that were paid
to you because the insured was terminally ill, skip lines 17 through 25 and enter -0- on line 26.
17
Gross LTC payments received on a per diem or other periodic basis. Enter the total of the
amounts from box 1 of all Forms 1099-LTC you received with respect to the insured on which the
“Per diem” box in box 3 is checked . . . . . . . . . . . . . . . . . . . . .
17
Caution: Don't use lines 18 through 26 to figure the taxable amount of benefits paid under an
LTC insurance contract that isn't a qualified LTC insurance contract. Instead, if the benefits aren't
excludable from your income (for example, if the benefits aren't paid for personal injuries or
sickness through accident or health insurance), report the amount not excludable as income on
Schedule 1 (Form 1040), line 21.
18 Enter the part of the amount on line 17 that is from qualified LTC insurance contracts . . . . 18
19
Accelerated death benefits received on a per diem or other periodic basis. Don't include any
amounts you received because the insured was terminally ill. See instructions . . . . . . .
19
20 Add lines 18 and 19 . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Note: If you checked “Yes” on line 15 above, see Multiple Payees in
the instructions before completing lines 21 through 25.
21 Multiply $360 by the number of days in the LTC period . . . . . . 21
22
Costs incurred for qualified LTC services provided for the insured
during the LTC period (see instructions) . . . . . . . . . . .
22
23 Enter the larger of line 21 or line 22 . . . . . . . . . . . . 23
24
Reimbursements for qualified LTC services provided for the insured
during the LTC period . . . . . . . . . . . . . . . . .
24
Caution: If you received any reimbursements from LTC contracts
issued before August 1, 1996, see instructions.
25 Per diem limitation. Subtract line 24 from line 23 . . . . . . . . . . . . . . . . .
25
26
Taxable payments. Subtract line 25 from line 20. If zero or less, enter -0-. Also include this
amount in the total on Schedule 1 (Form 1040), line 21. On the dotted line next to Schedule 1
(Form 1040), line 21, enter “LTC” and the amount . . . . . . . . . . . . . . . .
26
Form 8853 (2018)